How diminishing returns may render the surgical timeout ineffective

Wrong site surgery is never acceptable. A surgeon ought never to find himself in a situation where he has to inform the family that he just operated on the wrong body part. It is embarrassing, unprofessional, and an egregious violation of the patient/physician covenant.

That being said, we have allowed this issue to be defined entirely in terms of “systems management”. And hence the rise of the timeout and the checklist. The ultimate responsibility for identifying the proper surgical site has been diluted. No longer is it at the sole discretion of the operating surgeon. Now we have a team-based approach involving nurses, anesthesia personnel, mid level providers, and surgeons. Performance of a group timeout (of which I am actually a strong proponent) has quickly become the standard of care at most American hospitals prior to initial incision.

But the bureaucrats have taken a good idea and muddled it up in layers of unnecessary complexity. The simple timeout has been expanded and diversified. Now, for a routine elective surgery I am required to see the patient in the holding area for proper marking of the site (as applicable), to sign the H&P, and answer any questions the patient may have. This is a standard protocol. I have been doing exactly this same thing since I was a resident.

The next layer of the process occurs when the patient arrives in the OR. This is called the “sign in”. At this point we confirm that we have the right patient and are proposing to do the proper procedure. Once the patient is asleep we then perform the official timeout, which involves repeating the same facts already addressed at steps one and two. Finally, once I have scrubbed in and am ready to commence the case, we have to all participate in the pause. In the pause, I am supposed to repeat the same mindless data as in steps 1,2,and 3. Then, and only then, am I allowed to take the scalpel and begin.

On the surface, the casual reader may be thinking to herself, “well if it improves patient safety, what’s the big deal? You doctors are so arrogant.” To that I would respond, “then why don’t we make even more layers of screenings? If four steps are better than one, then why shouldn’t we be taking 8 or 10 mini-pauses prior to starting these cases?”

Why don’t we take a pause before I move on from one step of a gallbladder removal to the next? Why don’t we make checklists for “when it’s safe to put a clip on the cystic duct?” The truth is that once you state the pertinent facts of an case , i.e. patient name, procedure, which side, proper antibiotic, etc, each subsequent oration of said facts devolves ever more obscurely into rote recitation, mumbled and mindless. The fourth time we state the patient’s name and procedure, no one is paying any attention. Every one’s guard is down. We are fogged by a sense of false security. We did our timeout! Now it’s impossible something bad could occur!

No one seems to have considered the concept of the law of diminishing returns. Repetition is sometimes harmful. The surgeon may have marked the patient improperly to begin with. I don’t care if the team repeats the mindless mantra 50 times. If the initial evaluation was performed incorrectly, all the timeouts and pauses and huddles in the world will fail to salvage the patient from harm.

My primary problem with the whole overly complicated, multi-tasked process is that it disperses ultimate responsibility from individuals and focuses too much on broad, systemic solutions. For wrong site surgery, the ultimate responsibility lies with one person: the operating surgeon. If he is so lackadaisical and irresponsible to the extent that he needs a team-based, multi-layered algorithmic approach to preventing wrong site surgeries, then he really has no business ever drawing a knife again.

It’s about professional duty. A surgeon who doesn’t review his notes, who doesn’t re-examine the patient in the holding area and mark the proper side himself, is a surgeon who is on the road to having his privileges permanently revoked. Exempting surgeons from the consequences of unprofessional, negligent conduct only obscures the root cause of the problem.

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karen3

Brilliant. Social research is very clear that when “everyone” is responsible, nobody is responsible. If you want to improve “the system” improve the level of accountability for individuals.

Caitlin Peebles

This is a problem which goes way beyond medicine. I’ve been involved with health and safety systems on drill ships and oil & gas rigs and it’s the same story. Yes, the potential for disaster in both human and environmental terms is huge if something goes wrong, but over-engineering your safety systems to the point where things become rote and people risk tuning things out, and also adopting more of a “collective responsibility” mindset, can be real problems.

When you responded to your hypothetical reader-critic, “If four steps are better than one, then why shouldn’t we be taking 8 or 10 mini-pauses prior to starting these cases?”, I found myself nodding in recognition.

This article is a keeper. Thanks.

trinu

There’s the time factor. Taking the time to do a procedure correctly is one thing, making it necessarily long to satisfy bureaucrats just means taking time away from the patient, which they could be using to read, watch TV, think about their place in the universe or whatever. Patients should not be kept under anesthesia any longer than is necessary just to satisfy some “risk analyst” with no understanding of science, medicine, or statistics.

wahyman

Is there any actual evidence of harm from trying to improve safety. Or do we can adopt the new healthcare motto (suitable for embroidery on uniforms and signage). “Too Busy To Be Safe”

Caitlin Peebles

“Is there any actual evidence of harm from trying to improve safety.”

Yes. Take traffic safety for example. Red-light cameras were meant to lower the number of accidents at traffic lights by guaranteeing drivers that if they were out in an intersection after the light had turned red, they’d get a ticket in the mail. Therefore, everyone would be extra careful and there’d be fewer accidents at intersections. Instead, several jurisdictions found that they ended up with more accidents, because drivers were *so* incentivized to avoid even a yellow light in case it turned red before they cleared the intersection, that they’d slam on the brakes and the vehicles behind them were liable to smash right into them. Not everything that sounds like a good idea works out that way.

And then there’s the classic example of the speed limit. The more we lower the speed limit, the safer we’ll all be on the roads, right? So why not set the speed limit to 10mph? Or better yet, as in late-19th century England, why not require all vehicles to have a minimum crew of three: one to drive, one to navigate and observe, and one to walk 60 yards ahead of each vehicle carrying a red flag? Sure, the country would come to a screeching halt, but we’d be /safe/.

So we have the fact that not everything that seems like a good idea is; and we have the fact that safety systems can be over-worked to the extent that the process they were trying to improve now fails to function in any meaningful way at all. That’s why it’s a continuous process of trying something, evaluating it, keeping what worked, and not being afraid to abandon what didn’t. Rinse and repeat 🙂

wahyman

Nice examples I suppose, but I meant with respect to taking the time necessary to address wrong site surgery.

Caitlin Peebles

Have a think about it. It’ll click.

wahyman

That’s helpful.

Caitlin Peebles

I’m here to help. I’m a very helping person. Shall I hum the Jeopardy “thinking music” theme for you? I can do that.
😉

wahyman

Do Jeopardy and thinking belong in the same sentence?

wahyman

This would perhaps be a good theory if there had not been so much wrong site surgery that relying on the surgeon alone was proven to be dangerous to patients. The additional steps were made up to address a known problem, not just to amuse bureaucrats and annoy surgeons.

trinu

If the surgeon marked the wrong site, what makes you think a time out will fix it?

wahyman

Aren’t others suppose to confirm it?

Ryan

As a Flight Surgeon in the Air Force, I fly on a weekly basis. I sit for an hour before every flight and listen to the TEAM discuss the mission objectives. It’s not the pilot telling everyone else. It’s a TEAM approach.

Physicians have to let go of the mentality of being all knowing and infallible. Atul got it right with The Checklist Manifesto. The safety records of the aviation industry are undeniable and need to be explored more.

The “bystander” effect that karen3 talks about is not the same as a team approach. In the aviation world, when everyone clearly knows that no matter what their role, if you see something out of the ordinary, say something – it works.

Noni

I see this in clinical practice, and I imagine most of my colleagues would agree with me. A time out is done pre operatively at least twice now, and with each subsequent “TIME OUT” declared by the circulating nurse most of the staff’s eyes glaze over as we numbly listen to all of the details now required to be included (sometimes this even includes the operating room humidity level). It is losing it’s purpose and most certainly has already lost its effectiveness.